Corporate Giants and the government revolving door create costly and fragmented care

By: Marion Mass, M.D. and Craig M. Wax, D.O.

Insurers, Pharmacy Benefit Managers(PBM), advocacy groups  such as AARP, and others are using their amassed wealth and influence to game the over-complicated and burdensome healthcare system for their own profit on the backs of the American taxpaying patient while fragmenting their care.  Let’s follow one pathway of corporate profiteering that results in a poorer quality of patient care:

United Healthcare’s subsidiary Optum (the company formerly known as Inginex) is one of the three big PBM…  companies that control what drugs your insurance company pays for and how much, while having the government given right to receive kickbacks from pharma manufacturers (conflict of interest much?). These kickbacks are costing Americans $200 BILLION PER YEAR and a prime reason why Optum got so rich. Their 2018 profits put them at the 100 billion mark.

How did a company with a history of fraud get so rich? Round up the usual suspects of the government/corporate cronyism.

After the fraud charges,  Ingenix rebranded itself as Optum, it’s CEO Andy Slavitt left and in 2015 became the Head of Center for Medicare and Medicaid Services(CMS)  while the former head of CMS, nurse Marilyn Tavenner, left to become the president of the insurance industry’s  lobby group AHIP. Slavitt was able to cash out stock options TAX FREE, getting a $4 million windfall.

Curiously, in 2015, while Slavitt is running CMS, Optum seems to take over the publication and administration of the CPT and ICD coding, their logo appearing on the coding material.

As if kickbacks, and coding are not enough, Optum finds another revenue stream via home visits. They send clinicians to medicare advantage patient’s homes often incentivizing the patients with gift cards.  ( apparently they discovered that kickbacks work)  These “wellness visits” prevent patients from being able to see their primary care physician for an annual physical, thus fragmenting care, while failing to forward critical information to the patients’ physicians.

These visits seem designed for Optum to be able to increase risk scores, and thus collect more from Medicare. A possible scenario: order protein levels, often low in elderly patients, increase the patients risk score, and viola!  Optum collects more from Medicare, and thus from the pockets of TAXPAYERS. Apparently, someone in the Justice Department is paying attention, as United looks to be in the hot waters of fraud yet again.

All this money-making benefits the AARP, a formidable lobby force in DC. The AARP gets nearly 50% of its income from royalties the big insurance companies pay them to peddle Medicare advantage plans, the bulk from United/Optum. A mere  17% of AARP’s collections come from membership fees from its 37 million members.
https://capitalresearch.org/article/aarp-advocacy-group-or-crony-capitalists/

There you have it: big insurance and their PBM henchmen, hired by our government, teaming up with the AARP all getting rich gaming the system while Medicare patients get fragmented care and taxpayers pay more. Medicare advantage plans? They ought to call them “taking advantage of taxpayers plans. ”

Marion Mass, MD is co-chair of Practicing Physicians of America (PPA) and Craig M. Wax, DO is PPA’s VP of Health Care Policy.  Learn more: https://practicingphysician.org

Killer Algorithms at the Drug Store

Guest post by Barbara Duck, @MedicalQuack: http://ducknetweb.blogspot.com/

Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store

Here we go again.  If you haven’t figured this out yet, when you buy a Cigna Health insurance policy you get a two for one with 2 insurers.  Cigna provides the insurance benefits and then it’s pharmacy benefit manager, PBM OptumRX (biggest revenue sector subsidiary of United Healthcare) that runs all their formulas via the computer and tells the pharmacist what to charge you.  (Video at the break below-watch it!)

If You Are Insured byCigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare

Continue reading

Final MACRA rule still byzantine and unworkable, patients lose.

The final MACRA rule expands exemptions, flexibility, claims ModernHealthCare.com but it is still byzantine and unworkable. Patients lose.

The 2,398 page rule can be downloaded here: https://qpp.cms.gov/docs/CMS-5517-FC.pdf

We haven’t read the all 2,398 pages yet but here are a few initial notes:

  • The low-volume threshold is now < $30,000 in Part B billings OR < 100 Part B Patients.The proposed rule was < $10,000 AND < 100 Patients.
  • The infamous table from the proposed rule showing 87% of solo docs would face a negative adjustment under MIPS has been “bleached.” The sanitized table no longer lists solo physicians separately, and claims that only 10% of practices from 1 to 9 physicians will will face negative adjustment.  Click here for image combining both new table and old table. Supposedly, overall, 94.7% of eligible clinicians will get a positive or neutral adjustment with 5.3% receiving a negative adjustment.

Another trouble spot to look out for (Page 1513):

“One commenter supported the inclusion of ABMS board certification and participation in Maintenance of Certification (MOC) Programs on Physician Compare. Another commenter recommended MOC participation as a measure in future rulemaking as part of quality performance data publicly reported on Physician Compare … We appreciate the points, concerns, and suggestions raised by commenters and, if feasible and appropriate under the statute, we may possibly consider these issues in future rulemaking. ”

Some other low-lights:

Re Privacy:

“We disagree with commenters who maintained that the disclosure of PHI to ONC or an ONC-ACB (authorized certification body) could be inconsistent with reasonable privacy or other organizational policies or would otherwise be an unjustified invasion of privacy or any other interest. As noted, the disclosure of this information would be authorized by law on the basis that it is a disclosure to a health oversight agency (ONC) for the purpose of determining compliance with a federal program (the ONC Health IT Certification Program). In addition, we note that any further disclosure of PHI by an ONC-ACB or ONC would be limited to disclosures authorized by law, such as under the federal Privacy Act of 1974, or the Freedom of Information Act (FOIA), as applicable.” (page 67)

Data-Collection from all-payers:

“In addition, we are finalizing our approach of including all-payer data for the QCDR, qualified registry, and EHR submission mechanisms because we believe this approach provides a more complete picture of each MIPS eligible clinician’s scope of practice and provides more access to data about specialties and subspecialties not currently captured in PQRS” (page 468)

“We desire all-payer data for all submission mechanisms, to create a more comprehensive picture of the practice performance. Section 1848(q)(5)(H) of the Act authorizes the Secretary to include, for purposes of quality measurement and performance analysis, data submitted by MIPS eligible clinicians with respect to items and services furnished to individuals who are not Medicare beneficiaries. As discussed in section II.E.5.b. of this final rule with comment period, we are finalizing our proposal to require MIPS eligible clinicians to report allpayer data on quality measures where possible.” (pg1396)

CMS will be accepting comments for 60 days, however the online comment portal is not yet open as far as we can determine.  Stay tuned!

Be heard in Congress on MACRA – Submit testimony to Senate Finance Committee

On, July 13, 2016, The U.S. Senate Committee on Finance held a hearing on MACRA implementation, with Andrew Slavitt testifying.

Any individual or organization wanting to present their views for inclusion in the hearing record should submit a typewritten, single-spaced statement, not exceeding 10 pages in length. Title and date of the hearing, and the full name and address of the individual or organization must appear on the first page of the statement. Statements must be received no later than two weeks following the conclusion of the hearing.

Statements should be mailed (not faxed) to:

Senate Committee on Finance
Attn. Editorial and Document Section
Rm. SD-219
Dirksen Senate Office Bldg.
Washington, DC 20510-6200

MACRA: CMS Policy Nerd #Fail

One aspect perhaps not getting enough attention is how MACRA doubles down on price fixing for Medicare services. It’s price fixing coupled with increasingly complicated hoops to jump through; hoops that determine if a physician will get a small percentage more or less than the fixed price. But the costs and risks of jumping through the hoops far outweighs any potential gain for a solo physician. (It’s not really about paying physicians more anyhow but controlling costs under the guise of paying for quality.)

The CMS self-styled “innovation center policy nerds” think they are smarter than the free market at determining prices. They think they can create algorithms that somehow replace free market mechanisms to tie payment to value. The problem is that decades of Medicare payment policy developed by Medicare policy experts has resulted in one failure after another; flopped Medicare policies are actually responsible for divorcing payment from value. Why should we expect they are getting it right this time?

image (1)

Three Simple Steps CMS Can Take To Save Medicare for our Children

Dear Mr. Slavitt:

CMS can be the hero that saves Medicare for our children and grandchildren by simply starting out with these three steps:

1. Take the handcuffs off solo and small practices, which are the most efficient, productive, effective and inexpensive healthcare facilities available.
http://www.aafp.org/news/practice-professional-issues/20140820smallpractstudy.html

The stated goal of MACRA MIPS is to make care more available, inexpensive and productive. Per government data published in Medical Economics, 89% of solo practices will get hit with penalties and a majority of small practices of less than 10 physicians, some 110,00 physicians, will be also be penalized. All solo and small practices are potentially vulnerable to bankruptcy due to MACRA.
http://medicaleconomics.modernmedicine.com/medical-economics/news/your-voice-frustrations-quality-metrics-remain-intact Continue reading

MACRA empowers bureaucracy, not patients and their doctors

Richard Armstrong, MD of https://d4pcfoundation.org/ submitted the following comments to CMS in opposition to the 962-page MACRA proposed rule.  Comments are due 6/27.  Submit yours TODAY at http://bit.ly/macracomment

Good afternoon, Ladies and Gentleman,

My name is Dr. Richard Armstrong. I am a general surgeon who has been in practice for 35 years since completing post-graduate training. I have been in the military, in academics, in private practice and now employed. I have watched the development of the federal medical bureaucracy since 1976 and opposed more government intervention then in public in a letter to the Washington post. I did this as an active duty naval officer and received hundreds of letters of support.

In 2009 after President Obama spoke before a joint session of Congress about health care reform, I wrote to him with a simple specific request. I asked him to please speak with the doctors on the front lines, the dedicated physicians and surgeons who care for all of you and your families day and night…24/7. The fellow human beings who are there for you when you need us and who passionately care about our profession and our patients. Of course, my plea went unheeded, so I joined a group of concerned physicians and traveled to Washington to read my letter in public on October 1st, 2009. This was the beginning of a national movement to return the leadership of our proud profession to those who understand what it is to care for individual human beings, one at a time, face to face, with dedication, compassion and excellence. That movement is growing. Continue reading